Healthcare Provider Details

I. General information

NPI: 1013276880
Provider Name (Legal Business Name): ELLEN DIAMOND
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/14/2012
Last Update Date: 05/14/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1866 SHERIDAN RD STE 207
HIGHLAND PARK IL
60035-2545
US

IV. Provider business mailing address

1866 SHERIDAN RD STE 207
HIGHLAND PARK IL
60035-2545
US

V. Phone/Fax

Practice location:
  • Phone: 847-433-3815
  • Fax: 847-433-3203
Mailing address:
  • Phone: 847-433-3815
  • Fax: 847-433-3203

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number071004187
License Number StateIL

VIII. Authorized Official

Name: LANA MOSHKOVICH
Title or Position: CMM, CPC,CEMP
Credential:
Phone: 847-904-7500